I qualified as a physiotherapist in Johannesburg in 1981. In the model I was taught, pain was essentially a measurement. Damage in the tissue travelled up a nerve, arrived at the brain, and produced a sensation proportional to the injury. More damage, more pain. Find the damaged structure, fix the damaged structure, and the pain resolves.

It is a tidy model. It works reasonably well for a sprained ankle. And for the people I have spent the last four decades treating, the ones whose pain has outlasted every reasonable healing timeframe, it is wrong in a way that has done real harm.

I want to explain what changed, because it is the single most useful thing I know.

The scans that did not match

The first crack in the model, for me, was the imaging.

Once scans became routine, we started seeing something awkward. People with dramatic findings on their films who were out working and playing sport and had never had a day of back pain. And people whose scans came back unremarkable who could not sit through a meal. If pain were a readout of tissue damage, those two groups should not exist. They exist everywhere.

The second crack was watching what happened when I told people what their scan said. I would use the words on the report, because they were the accurate words. Degeneration. Bulging. Tear. And I would watch a person become smaller in front of me. They would move more carefully afterwards. They would stop doing things. And they would hurt more.

I was, without intending to, making people worse with information.

What pain actually is

Here is the reframe, and I want to be careful with it because it is easily misheard.

Pain is not a message sent up from the tissue. Pain is a decision made by the nervous system about whether you need protecting. It draws on information from the tissue, absolutely, but it also draws on context, on your previous experiences, on how much you slept, on what you believe the pain means, on what you have been told, and on what happened last time you moved this way.

That is why a papercut can be agonising and why people have walked kilometres on broken bones to get help. Same tissue signal, different situation, different decision.

When that protective system stays switched on for months, it becomes better at its job. The threshold drops. Movements that used to be fine start to hurt. The painful area spreads beyond where the original problem was. This is called sensitisation, and it is a normal adaptation in a system doing exactly what it was designed to do. It is not damage. It is not weakness. And critically, it is not permanent, because a system that learned to be sensitive can learn the other way.

The sentence that matters

Hurt does not always mean harm.

I say this to people most days and I know how it lands the first time. It sounds like I am about to tell you the pain is not real, or that you should ignore it, or push through it. I am not saying any of those things.

Your pain is entirely real. All pain is produced by the brain, including the pain of a fracture, and that has never made any of it imaginary. What I am saying is narrower and more useful: once the system is sensitised, pain stops being a reliable report on the state of your tissues. The alarm is now going off at a lower threshold. Movement that hurts is very often not movement that is damaging you.

And that changes everything about treatment. If pain equals damage, the logical response is avoidance, and avoidance is what most people arrive having done. They have stopped bending, stopped lifting, stopped walking far, stopped going out. Their world has contracted to the small set of things that do not provoke it. Every one of those decisions was rational. Collectively they have made the system more protective, not less.

The way out is the opposite direction, taken carefully. Slightly more than yesterday, consistently, so the nervous system accumulates evidence that these movements are safe. Not heroics. Not pushing through. Small, boring, repeated exposure. This is the least glamorous treatment in physiotherapy and it is the one that works.

What I have watched help

Understanding this, properly, changes pain for a lot of people on its own. That is not a motivational statement, it is one of the more robust findings in the field, and it is why I spend so much of a first appointment talking.

Sleep matters more than people expect. A poor night measurably lowers pain thresholds the following day, and for many people the sleep and the pain have been feeding each other for years.

Stress and mood turn the volume up. They are not the cause of your pain and I would never suggest they were. But a nervous system already on alert does not need more reasons to protect you.

Movement you actually enjoy beats the theoretically optimal program every time, because the optimal program you abandon in February does nothing. I trained in dance before I trained in Pilates, and I have never stopped believing that people move better when they are enjoying themselves.

Hands-on treatment has a place. A useful place, as part of a plan, giving you a window in which to move more freely. Not as the plan itself.

What I would say if you are two years in

Most people who come to me with persistent pain have already seen several practitioners. They are tired of explaining themselves. They half expect to be disbelieved, and quite often they have been.

So, two things.

Progress is not linear and flare ups are not a return to the start. They feel exactly like a return to the start, which is the cruel part. They are not. The trend across months is what tells you what is happening, not any individual week.

And a life not organised around pain is a realistic goal even when some pain remains. Many people do become pain free. For others the win is that they stopped planning their week around it, and that is a genuine win rather than a consolation prize. I will always be honest with you about which one I think we are aiming at.

After forty five years I am still doing this work, and it is this part of it that keeps me here. Not the tissue. The point at which somebody realises their body is not broken, and starts doing things again.

If you have been carrying pain for a long time and want an assessment that takes the whole picture seriously rather than looking for something on a scan, you can book an appointment at our Elsternwick clinic.